A national survey of inpatient medication systemsin English NHS hospitalsMonsey McLeod1*, Zamzam Ahmed1, Nick Barber1,2 and Bryony Dean Franklin1
Abstract
Background: Systems and processes for prescribing, supplying and administering inpatient medications can havesubstantial impact on medication administration errors (MAEs). However, little is known about the medicationsystems and processes currently used within the English National Health Service (NHS). This presents a challenge fordeveloping NHS-wide interventions to increase medication safety. We therefore conducted a cross-sectional postalcensus of medication systems and processes in English NHS hospitals to address this knowledge gap.
Methods: The chief pharmacist at each of all 165 acute NHS trusts was invited to complete a questionnaire formedical and surgical wards in their main hospital (July 2011). We report here the findings relating to medicationsystems and processes, based on 18 closed questions plus one open question about local medication safetyinitiatives. Non-respondents were posted another questionnaire (August 2011), and then emailed (October 2011).
Results: One hundred (61% of NHS trusts) questionnaires were returned. Most hospitals used paper-based prescribingon the majority of medical and surgical inpatient wards (87% of hospitals), patient bedside medication lockers (92%),patients’ own drugs (89%) and ‘one-stop dispensing’ medication labelled with administration instructions for use atdischarge as well as during the inpatient stay (85%). Less prevalent were the use of ward pharmacy technicians (62% ofhospitals) or pharmacists (58%) to order medications on the majority of wards. Only 65% of hospitals used drug trolleys;50% used patient-specific inpatient supplies on the majority of wards. Only one hospital had a pharmacy open 24 hours,but all had access to an on-call pharmacist. None reported use of unit-dose dispensing; 7% used an electronic drugcabinet in some ward areas. Overall, 85% of hospitals had a double-checking policy for intravenous medication and58% for other specified drugs. “Do not disturb” tabards/overalls were routinely used during nurses’ drug rounds on atleast one ward in 59% of hospitals.
Conclusions: Inter- and intra-hospital variations in medication systems and processes exist, even within the EnglishNHS; future research should focus on investigating their potential effects on nurses’ workflow and MAEs, anddeveloping NHS-wide interventions to reduce MAEs.
Keywords: Health care surveys, Medication systems, Pharmacy service hospital, Medication storage
BackgroundSystems and processes used to prescribe, supply, store,and administer medicines can have a substantial impacton medication administration errors (MAEs) in hospitalinpatient settings [1-8]. Nursing staff potentially play a keyrole in intercepting all types of medication errors and thuspreventing patient harm; however nurses are also them-selves susceptible to making errors [9,10]. Inadequate
nurse staffing (numbers, skill mix, knowledge and experi-ence) is a major potential patient safety concern [11-15].Furthermore, increasing cognitive workload during medi-cation administration as a result of system-related factorssuch as interruptions has been associated with both actualand perceived risk of MAEs [16,17]. Coupled with organ-isational pressures to reduce costs and increasing de-mands on the health service, there is an urgent need todevelop systems and processes to increase efficiency andsupport the delivery of high quality safe care. In England,health care is primarily delivered by one publicly fundedorganisation, National Health Service (NHS) England.
* Correspondence: [email protected] Centre for Medication Safety and Service Quality, PharmacyDepartment, Imperial College Healthcare NHS Trust and Department ofPractice and Policy, UCL School of Pharmacy, London, UKFull list of author information is available at the end of the article
However, little is known about medication systems andprocesses currently used within the English NHS; this pre-sents a challenge for developing NHS-wide interventionsto increase medication safety.Unlike in the United States (US) [18,19], there has
been no comprehensive national survey of hospitalmedication systems in English hospitals. A 1992 surveyof clinical pharmacy services in UK NHS hospitals [20]reported the extent to which various activities were car-ried out. This survey reported that 9% of hospitals had aresident on-call pharmacist and 88% had a non-residenton-call service to provide advice and support medicationsupply outside of pharmacy opening hours. However,these data are now over 20 years old and various na-tional medication safety and quality initiatives have sincebeen introduced in NHS hospitals. These include theuse of electronic prescribing and medication administra-tion (EPMA) systems, the use of patients’ own drugs(PODs) during hospital inpatient stays, one-stop dis-pensing (OSD) supplies which are hospital inpatientmedications labelled with administration instructions foruse at discharge as well as during the inpatient stay, andpatient bedside medication lockers [21-23]. These inter-ventions evolved from the recognition of common prob-lems across the NHS. However, the extent to whichthese initiatives have been implemented across Englishhospitals is unclear. This gap in knowledge presents apotential barrier to developing systems-based interven-tions to support the safety and quality of medication ad-ministration. We therefore conducted a national surveyof hospital medication systems in English NHS hospitalswith the aim of describing the medication administrationrelated systems and processes used. Specifically, wewanted to summarise (1) the systems and processes usedfor prescribing, supply, storage, transport, and adminis-tration of medications on general medical and surgicalinpatient wards; and (2) local strategies introduced withthe aim of reducing MAEs.
MethodsWe conducted a national cross-sectional postal census ofEnglish NHS hospital inpatient medication systems in July2011. At the time, the English NHS was geographically di-vided into 10 strategic health authorities (SHAs) [24], eachresponsible for overseeing local health services includingone or more acute and/or foundation NHS hospital trusts,where foundation trusts have more financial and oper-ational freedom than non-foundation trusts. There were atotal of 165 acute and foundation NHS trusts; each hadone or more acute or specialist hospitals.A pre-notification letter was sent to the chief pharma-
cist at each trust in June 2011, followed by an invitationto complete a questionnaire relating to inpatient medicaland surgical wards in their main acute hospital in July
2011. To potentially increase the response rate [25], abusiness-franked return envelope was provided, the chiefpharmacist was encouraged to delegate questionnairecompletion by a deputy if appropriate, and our contact de-tails were included. In addition, non-responders were sentanother invitation, questionnaire and business-franked re-turn envelope in August 2011, and then an electronic re-minder sent to non-responders for whom we had emailaddresses in October 2011.The questionnaire (see Additional file 1) comprised
two parts with questions relating to medication systemsand processes in part 1, and more detailed questions re-lating to any electronic prescribing systems used in part2 (data presented elsewhere) [26]. All questions (bothparts) were initially piloted with a range of health careprofessionals, followed by 15 hospital pharmacists ofvarying experience across four trusts to test face validityand internal consistency. One of two researchers (MMand ZA), who were familiar with hospital medicationsystems, also observed each respondent as they com-pleted the questionnaire; in order to assess content val-idity, respondents were asked to report any problemsduring completion in addition to general feedback. Part1 of the final questionnaire incorporated a number offindings from pilot work, mainly: (1) a brief explanationto emphasise the importance of the survey was included,(2) an option for respondents to select ‘one ward’ wasincluded in questions where ‘all wards’, ‘most wards’,‘some wards’, ‘no ward’ and ‘not sure’ were standard op-tions, and (3) two open questions were combined. Thispaper presents the data from part 1 which comprised 18closed and one open question. The 19 questions coveredfive areas which reflected the objectives of this study:(A) hospital demographics, (B) prescribing and medi-cation administration records, (C) medication orderingand supply (including pharmacy services), (D) ward-based medication storage and transport during nurses’drug rounds, and (E) medication administration pro-cesses, policies, and guidance. Eight questions had mul-tiple parts that involved selecting one option from six:“all wards”, “most wards”, “some wards”, “one ward”, “noward”, or “not sure”. Where relevant, respondents werealso asked to identify and rank the three most commonsystems or practices used in their hospital. Three otherclosed questions had multiple parts; these involved therespondent selecting one option from three (“yes”,“no”, “not sure”) in response to whether a specificadministration-related policy or guidance was available.The open question asked about local medication safetyinitiatives.All completed questionnaires returned by 1 November
2011 were included in the data analysis. Questionnaire re-sponses were transcribed and analysed using descriptivestatistics within Microsoft Excel (MM). Characteristics of
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respondents and non-respondents were compared usingparametric and non-parametric statistical tests as appro-priate for the distribution of the data concerned. Tran-scription of a random 20% of questionnaires was verifiedby ZA and discrepancies reviewed jointly and resolved; athird reviewer was available to resolve any remaining dis-agreements but was not required. One additional com-pleted questionnaire received in December 2011 wasexcluded, as were specific questions omitted by individualrespondents. For questions relating to the proportion ofwards that used a specific system or process, responses for‘all wards’ and ‘most wards’ were combined into ‘majorityof wards’ in our analysis of inter-hospital variation. Intra-hospital variations were identified by reviewing responsesfor questions for which ‘some wards’ and ‘one ward’ wasselected; responses for ‘no ward’ was described separately.We conducted additional analysis by SHA of hospitals inwhich EPMA systems were used in the majority of wards.The study was approved by the relevant School of
Pharmacy Research Ethics Committee in June 2011. TheJoint Research Office at Imperial College London andImperial College Healthcare NHS Trust confirmed thatNHS research ethics approval was not required as thestudy was considered to be service evaluation.
ResultsOverviewOverall, 100 (61%) questionnaires were returned: 57(35%) initially and 43 (26%) after follow-up. Respondentswere from 59 of 93 (63%) foundation NHS trusts and 41of 72 (57%) acute NHS trusts. Median response rate perquestion was 97% (range 64-100%). Characteristics ofrespondent and non-respondent trusts are summarisedin Table 1; no statistically significant differences wereidentified.An overview of specific inpatient medication systems
used on the majority of medical and surgical wards is pre-sented in Table 2. Overall, the majority of hospitals usedpaper-based inpatient prescribing for the majority of med-ical and surgical inpatients (87% of usable responses), pa-tient bedside medication lockers (92%), ward stock (94%),PODs (89%), and OSD (85%). Ordering medications from
pharmacy staff during their ward visit was more prevalentthan other methods of ordering medications; the preva-lence of different ordering methods varied between 13%and 62% of usable responses. Hospitals also varied in theiruse of drug trolleys to store medicines (59% of usable re-sponses) on the majority of medical and surgical wards,methods used to transport medicines during drug rounds(between 8% and 65% among four different methods),and the use of non-OSD supplies which are medicinesintended for use during the inpatient stay that are labelledwith the patient’s name but not with instructions for ad-ministration (50%).
Prescribing and medication administration recordsThe 13 hospitals in which an EPMA system was used onthe majority of inpatient medical and surgical wardswere mainly located in the northern SHAs (Figure 1).Exploratory analysis suggested that EPMA systems weremore likely in foundation than acute trusts (13 founda-tion trusts versus 0 acute trusts, p = 0.001, chi-squaretest). Of all 100 respondent hospitals, an additional 6(6%) also used an EPMA system on ‘one’ or ‘some’ med-ical and/or surgical wards; other wards in the same hos-pital used a paper-based inpatient prescribing system.More details of the EPMA systems used are presentedelsewhere [26].
Medication ordering and supply (including pharmacyservices)One respondent hospital had a pharmacy open 24 hours aday. Of the remaining 99 hospitals, the pharmacy wasopen for a median of 9 hours on weekdays (95% confi-dence interval 9–10 hours), 5 hours on Saturdays (95% CI4–5 hours), and 3 hours on Sundays (95% CI 2–4 hours).The pharmacy in 3 (3%) hospitals was not open on Satur-days or Sundays, and the pharmacy in a further 26 (26%)hospitals was open on Saturdays but not Sundays. To sup-port medication supply outside pharmacy opening hours,90 (90%) respondent hospitals had a non-resident on-callpharmacist and 9 (9%) had a resident [on-site] on-callpharmacist. There was a non-significant trend towardshospitals with a non-resident on-call pharmacist being
Table 1 Comparison of respondent and non-respondent trusts
Trust characteristic Respondents(n = 100 trusts)
Non-respondents*(n = 65 trusts)
Statistical analysis
Median number of acute hospitals in trust(range)
1 (1–5) 1 (1–5) p = 0.08; Mann–Whitney test
Median number of wards at main acute hospital(range)
25 (3 – 60) 23 (1–44) p = 0.12; Mann–Whitney test
Services provided by main acute hospital Adults (13) or paediatrics (1) only:14 (14%)
Adults (2) or paediatrics (3) only:5 (8%)
p = 0.21; Chi-square test
Mixed: 86 (86%) Mixed: 60 (92%)
*Data obtained from the trust websites.
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Table 2 Key features of inpatient medication systems used on the majority of medical and surgical wards
Systems and processes Number of respondent hospitals (% of usable responses)
Prescribing and administration record ■ Paper versus electronic prescribing system
87 (87%) used paper drug charts
13 (13%) used an EPMA system
Medication ordering and supply ■ Methods used to order medications during pharmacy opening hours†:
59 (62%) via the ward pharmacy technician (during their ward visit)
55 (58%) via the ward pharmacist (during their ward visit)
26 (29%) via the ward pharmacist (outside of their ward visit)
24 (26%) by taking drug charts to the pharmacy
12 (13%) by computer/electronically
5 (5%) selected ‘other’: ‘pneumatic tubes’ (n = 2), “pharmacy teams are ward based” (1), “bleeping[paging] the sweep pharmacist [designated to order medication across a range of wards] in theafternoon” (1), “nurse ordering” (1).
■ Methods used to obtain medications outside pharmacy opening hours†:
97 (97%) borrowed medicines from another ward
96 (96%) contacted the on-call pharmacist
89 (89%) used a non-electronic reserve drug cupboard
39 (39%) borrowed from another patient’s hospital supply (on the same ward)
11 (11%) used an electronic reserve drug cupboard
9 (9%) selected ‘other’: asked the family to bring in PODs (n = 5), accessed a dispensing robot viathe on-call pharmacist (2), medicines were not generally ordered outside of hours (1), 24-hourpharmacy (1).
■ Types of medication supply for inpatient administration†:
89 (94%) used ward stock
85 (89%) used PODs
82 (85%) used OSD supplies from the hospital pharmacy
46 (50%) used non-OSD supplies from the hospital pharmacy
3 (3%) selected ‘other’: all referred to the use of pre-labelled packs
Ward-based medication storage and transportduring nurses’ drug rounds
■ Ward-based medication storage† (see also Figure 5):
91 (92%) used patient bedside medication lockers
55 (59%) used drug trolleys
■ Medication transport during drug rounds†:
64 (65%) used drug trolleys
31 (43%) used medicines cup/oral syringe
10 (14%) used a tray/basket
6 (8%) used a temporary trolley (for example, dressing trolley)
2 (2%) selected ‘other’: 1 used “PRN lockers per bay”, 1 “drugs cupboard in [each] 6-bedded bay”
97 (98%) had an ‘out of hours access to medications’ guidance document
95 (97%) had guidance document on what to do if a drug was not available
90 (93%) had a ‘patient self-administration’ policy
80 (92%) had a ‘nil-by-mouth’ policy
98 (99%) had an IV guide: 71 (73%) paper-based version, 81 (82%) electronic
†Percentage total was over 100 as more than one option could be selected by the respondent.EPMA, electronic prescribing and medication administration; IV, intravenous; NHS, National Health Service; OSD, one-stop dispensing; PODs, patients’ own drugs;PRN, pro re nata or ‘when required’.
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smaller (mean 25 wards per hospital, 95% CI 23–28) thanthose with a resident pharmacist (mean 33 wards per hos-pital, 95% CI 23–43). There was also a non-significant dif-ference in out-of-hours pharmacy service among NHStrusts; a non-resident on-call pharmacist was less likely tobe found in foundation trusts (42% acute, 58% foundation)than a resident pharmacist (acute 22%, foundation 78%)(p = 0.42, chi-square with Yates’ correction).A total of 96 respondents answered the question about
frequency of ward pharmacist visits; the majority of hos-pitals (86; 90%) had at least one daily pharmacist visit onmost wards every weekday (Figure 2). An overview ofmedication ordering methods used by respondent hospi-tals (both during and outside pharmacy opening hours)
is presented in Table 2. As more than one method couldbe used in each hospital, respondents were also asked torank the three methods that were most common duringpharmacy opening hours (Figure 3). A sub-analysis ofthe 14 (15%) hospitals that had both a ward pharmacistand a pharmacy technician on the majority of wards re-vealed that the most common method for ordering med-icines was via the ward pharmacist during their wardvisit (6; 43%), followed by the ward technician duringtheir ward visit (5; 36%), and one (8%) of each of: takingthe drug chart to pharmacy, via the computer/electron-ically, and other ward-based pharmacy teams.In general, the majority of respondent hospitals used
ward-stock, OSD supplies, and PODs on the majority ofmedical and surgical wards (Figure 4). However, inter-and intra-hospital variation was prevalent for the use ofnon-OSD supplies. Three respondents additionally se-lected ‘other’ and specified the use of pre-labelled packs(medicines pre-labelled with standard dosage instruc-tions but not the patient’s name) for inpatient use. Nonereported the use of unit dose dispensing. When askedabout the most common type of medication supply usedon inpatient wards, 31 (34%) respondents reported PODs,31 (34%) reported OSD, 27 (30%) reported ward-stock,and 1 (1%) reported non-OSD supplies.
Ward-based medication storage and transport duringnurses’ drug roundsOverall, four of 11 types of medication storage facilitywere available on the majority of wards in respondents’hospitals: a non-electronic controlled drugs (CD) cup-board, patient bedside medication lockers, medicinesstock cupboards, and a fridge (Figure 5). Use of drugtrolleys was associated with the most intra-hospital vari-ation; 31% of respondent hospitals used these on somewards only. Exploratory analysis by SHA suggests thatdrug trolleys remain widely used in the South Central
Figure 1 Prevalence of inpatient electronic prescribing andmedication administration (EPMA) systems in English NHStrusts, presented by strategic health authority (SHA). Figuresrefer to number of trusts (percentage within each SHA) that had anEPMA system on the majority of inpatient medical and surgicalwards in their main acute hospital.
Figure 2 Frequency of ward pharmacist visits in English NHS hospitals. Totals do not sum to 100% as a number of respondents selectedanswers that indicated ‘majority of wards’ for a particular option and therefore the remaining options were not applicable.
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(all 3 respondent hospitals) and London SHAs (6 of 7hospitals), and least used in the North West (3 of 11hospitals) and East Midlands SHAs (2 of 7 hospitals).When asked about the most common medication stor-age used to retrieve medications at the time of admi-nistration, the majority (71; 72% of 98 respondents)reported patient bedside medication locker, drug trolley(15; 16%), medicines cupboards (10; 11%), and patients’bedside table or belongings (2; 2%). There were alsointer- and intra-hospital variations in the methods usedto transport medicines to patients during drug rounds(Table 2 and Figure 6). Three respondents selected‘other’ methods to transport oral medicines: “PRN (prore nata; when required) lockers per bay” on the majorityof wards in one hospital, “drugs cupboard in 6-beddedbay” on some wards in one hospital, and “individual
items carried by nurse (in hands)” on some wards in onehospital.
Medication administration processes, policies, and guidanceRespondents were asked if double-checking prior to admin-istration was required for five specific groups of drugs: 82(85% of 97 usable responses) stated ‘yes’ for IV medications,63 (65%) for IV fluids, 94 (97%) for parenteral chemother-apy, 73 (75%) for oral chemotherapy and 81 (83%) forpaediatric doses. Double-checking of CDs was excludedfrom this question as this is a legal requirement in the UK.When asked an open question about which other specificdrugs required double-checking prior to administration, 37(58% of 64 usable responses) respondents reported 15 typesof drug (Table 3). The route of administration of additionalnamed drugs was not specified by the respondents.
Local medication safety improvement initiativesA total of 56 (59% of 95 usable responses) respondentsreported the routine use of a ‘do not disturb overall/sash’by nursing staff during medication administration on atleast one ward in their hospital. Administration of medi-cations by a patient’s carer was routinely practised on atleast one ward in 24 (27% of 89 usable responses) of re-spondents’ hospitals; of these, 23 were in mixed adultand paediatric hospitals and 1 was in an adult-only hos-pital. Overall, seven other strategies were described by32 respondents (Table 4). The most frequently reportedlocal initiatives were based on expanding ward pharmacyservices and near-patient dispensing.
DiscussionMain findingsThis paper reports for the first time the prevalence of anumber of core medication systems in English NHS
Figure 3 Methods used to order non-stock medicines by ward staff in English NHS hospitals. Totals do not sum to 100% as respondentswere asked to rank the three most common methods rather than rank all methods.
94 89 85
50
6 11 15
29
21
0102030405060708090
100
Ward stock(n=95)
Patient'sown drugs
(n=96)
OSDsupplies(n=97)
Non-OSDsupplies(n=92)
Percentage of
respondent hospitals
Majority of wards Some wards No ward
Figure 4 Types of medication supply used for inpatientmedication administration in English NHS hospitals.n represents the number of complete responses for each typeof medication supply. OSD, one-stop dispensing.
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hospitals. The majority of hospitals used paper-basedprescribing (87%), patient bedside medication lockers(92%), ward stock (94%), PODs (89%), and OSD supplies(85%) in the majority of inpatient medical and surgicalwards. However, hospitals varied in the methods used toorder medications during pharmacy opening hours, par-ticularly in relation to whether medicines were orderedvia the ward pharmacist or a ward pharmacy technician.
There were also inter- and intra-hospital variations inpractices that were standard prior to the national intro-duction of PODs, OSD, and patient bedside medicationlockers; this included use of drug trolleys to store andtransport medicines, use of other methods to transportmedicines during drug rounds, and the use of non-OSDsupplies for inpatient use. Such variations suggest hos-pitals have implemented these national initiatives in
CD cupboard (non-electronic) 95
Patient's bedside medication locker 99
Medicines stock cupboard 92
Fridge 95
Drug trolley (non-electronic) 93
Patient's bedside (not in locker) 89
Patient container (not at bedside) 89
Shelves or units without doors 88
Electronic storage cabinet (stationary) 91
CD cupboard (electronic) 91
Electronic drug trolley 91
59
91
91
92
99
2
7
9
17
31
9
9
8
0
100
98
93
91
83
78
10
Majority of wards Some wards No ward
Figure 5 Availability of different ward-based medication storage facilities on wards in English NHS hospitals. n represents total numberof respondent hospitals for each medication storage facility. CD: controlled drugs.
Figure 6 Methods used to transport oral medicines during drug rounds in English NHS hospitals. n represents the number of completeresponses for each method used to transport oral medications to patients.
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different ways. Exploratory analysis by SHA suggests thatthere were some geographical differences in the use ofdrug trolleys and non-OSD supplies. In addition, we havedocumented the prevalence of a number of medicationadministration related policies, guidance and double-
checking practices. Across English NHS hospitals, currentefforts reported by pharmacy respondents to improvemedication safety appear to concentrate on extendingward and clinical pharmacy services.
Comparison with previous researchThis is the first national survey of medication systemsused in English NHS hospitals. Previous surveys, both inthe UK and elsewhere, have focused only on pharmacyservices [18,20,27,28] and therefore many aspects of oursurvey findings cannot be compared with existing lite-rature. A recent European survey [28,29] of hospitalmedication procurement and distribution suggested that37.5% of an unreported number of United Kingdom(UK) hospital pharmacies provided a unit-dose service;however it is unclear what was meant by a ‘unit-doseservice’ and how this question was framed. Furthermore,the UK response rate was very low; 35% of an unre-ported number of questionnaires were returned and only9% overall were usable after adjusting for unansweredquestions. Comparison of our pharmacy-specific findingswith those from a UK-wide clinical pharmacy surveyconducted in 1992 [20], suggest that more hospital phar-macies are now providing a weekend service: 74% of UKhospitals were open on Saturdays in 1992 versus 90% ofEnglish hospitals in 2011, 10% of UK hospitals wereopen on Sundays in 1992 versus 74% of English hospitalsin 2011. However, the percentage of hospitals thatprovide a resident on-call pharmacy service (9% ofUK hospitals in 1992 versus 9% of English hospitalsin 2011) and non-resident on-call pharmacy service
Table 3 Additional information provided by 64 respondentson specific drugs that required double-checking prior toadministration
Drug name/group No of respondenthospitals (%)
Double checking of specific drugs required butnames of drugs not provided
27 (42)
Insulin 16 (25)
Heparin 7 (11)
Complex preparations 6 (9)
Potassium 5 (8)
Epidurals 3 (5)
Infusion devices 2 (3)
Oral methotrexate 2 (3)
Saline [sodium chloride 0.9%] flushes 2 (3)
Therapeutic doses of low molecular weightheparins
2 (3)
Clinical trial drugs 2 (3)
“High risk” [unspecified] intravenous drugs 1 (2)
Intravenous immunoglobulin 1 (2)
Midazolam 1 (2)
Paediatric doses requiring calculations 1 (2)
Total percentage is over 100% as some respondent hospitals had more thanone drug-specific double-checking policy in place.
Table 4 Local initiatives reported in use in English NHS hospitals to improve medication safety
Local initiative Number ofhospitals
Examples
Extensive ward pharmacy technician and/orward pharmacy assistant service
10 Technician discharge transcribing service
Trial of technician medication administration
Near-patient dispensing 9 Use of mobile dispensing units, satellite dispensary, and pre-labelled packs
Extended pharmacy services to wards 7 Increased frequency of ward pharmacy visits, increased pharmacy opening hours, andprovision of pharmacy service to wards on weekends
Use of OSD and PODs 6
Self-administration schemes 4 Specific self-administration scheme for patients with Parkinson’s disease and separatelyfor maternity units, and an ‘opt-out’ patient self-administration scheme
Technology 3 EPMA, automated medication storage cabinets (for example, Omnicell®), an electronicdischarge prescribing system, and an electronic prescription tracking system
Quarterly medication storage review on wards 2
Other 8 Director/matron walkabouts with medicines checks on wards to identify potentialmedication problems and provide immediate feedback to ward staff, fast-trackmedication request system, pneumatic tube system, non-OSD supplies beingadditionally labelled with “inpatient supply only” to remind staff not to issue these topatients on discharge, standard operating procedures for nurses on specificadministration processes, target turnaround times for inpatient supply, and changedorder of tasks during drug administrations with IVs administered first followed bymedicines on a critical list then other non-IV medications.
EPMA, electronic prescribing and medication administration; IV, intravenous; OSD, one-stop dispensing; POD, patients’ own drugs.
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(88% of UK hospitals in 1992 versus 90% of Englishhospitals in 2011) are similar.
Implications for practiceIdentifying similarities across the NHS provides an im-portant context for those seeking to develop and prioritisesystems-based interventions to increase medication safety.However, identifying and exploring differences betweenhospitals enables advantages and disadvantages of themedication systems to be better understood, and thereforeinform future developments in their design, application,and/or implementation. Two of the variations we identi-fied in medication systems were unexpected: (1) medica-tion storage and transport (specifically relating to the useof drug trolleys), and (2) types of medication supply (spe-cifically relating to the use of non-OSD supplies of in-patient medication).
Medication storageInter- and intra-hospital variations in drug trolley useare difficult to interpret as drug trolleys serve the twofunctions of storage and transport. The introduction ofpatient bedside medication lockers around 2001 was notexplicitly intended to eliminate the use of drug trolleys;patient bedside medication lockers were advocated to fa-cilitate inpatient self-administration and the use of PODs[21]. Furthermore, bedside medication lockers could notreplace the ‘transport’ function of drug trolleys. Howeverour survey revealed drug trolley use to be relatively low;drug trolleys have previously been reported as a standardcomponent of medication administration during drugrounds in UK hospital inpatient wards, although with noquantitative substantiation [5,30]. Data from our surveyalso suggest that staff in some hospitals are using otherdevices to transport medications, for example, a tray ora basket, with or without a dressing trolley, to transportmedications to the patient’s bedside during drug rounds.These alternative solutions may have arisen from theneed to transfer medications from stock cabinets to thepatient’s bedside where medication is not stored in thepatient’s bedside medication locker, either due to lack ofspace or because it may be inefficient to store commonlyused medicines in each locker The implication is thatthere may be a role for re-introducing lockable drugtrolleys or some sort of lockable and/or wheelable devicefor transporting medications to the patient’s bedside onsome wards. Further research is needed to identify theeffects of using different devices to transport medica-tions during drug rounds. In addition, we suggest re-search should also seek to identify the environmentaland process-related factors associated with achievingmaximum benefit from the use of different medicationtransport devices.
Types of medication suppliesFindings suggest only 50% of English hospitals now usenon-OSD inpatient supplies compared with what wouldhave been standard prior to the introduction of OSD. “[ByApril 2002] all hospitals will have a ‘one stop dispensing/dispensing for discharge’ schemes”. This was one of themilestones set by the Department of Health in the NationalService Framework for Older People (2001), which wastaken further by the Audit Commission (2001) to promoteoriginal pack dispensing and patient self-administrationschemes, alongside implementation of patient bedsidemedication lockers. However, it was not explicit in thesedocuments whether or not traditional ‘non-OSD’ inpatientsupplies still had a role. Ten years on, our results revealuse of OSD supplies to some extent in all hospitals, and onthe majority of inpatient wards in 85%. This high uptakemay indicate that the potential benefits of OSD have trans-lated into real benefits in practice; this may also explainwhy only 50% hospitals continue to use non-OSD inpatientlabelled supplies on the majority of wards and 21% of hos-pitals do not use these at all. However, further research isrequired to substantiate these speculations and to explorethe rationale for dispensing all inpatient medication asOSD supplies, even for inpatient medication which is ex-tremely unlikely to be continued at discharge.
Strengths and limitationsA strength of our study was the census approach. Inaddition we achieved a higher than previously reported re-sponse rate (61%) compared with other similar surveys inthe US (40% and 29% of hospitals; Pedersen 2012; 2011,respectively), and for the UK response (35%) in a recentEuropean survey [28]. Responses in the present study alsorepresented a range of hospital sizes from both acute andfoundation NHS trusts.The main limitation was that we focused on English
NHS hospitals and therefore the findings cannot be ex-trapolated elsewhere. Second, for simplicity we asked re-spondents to report for their main acute hospital if therewas more than one in their trust; this was based on theassumption that hospitals within the same trust arelikely to have the broadly the same systems and pro-cesses. Third, some parts of the questions were not com-pleted by all respondents; however only three questionshad a response rate of less than 80% and therefore un-likely to have affected interpretation of the majority ofthe results. These three questions asked if there werespecific drugs that required a double-check prior to ad-ministration (64% of respondents answered this ques-tion), whether a tray or basket was used to transportmedications on all, most, some, one or no wards (71%),and if a medicines cup or oral syringe was used on all,most, some, one, or no wards (72%). Fourth, a smallnumber of questions asked respondents to describe use
McLeod et al. BMC Health Services Research 2014, 14:93 Page 9 of 11http://www.biomedcentral.com/1472-6963/14/93
of the system ‘in their experience’; responses for thesesubjective questions should therefore be interpreted withcare. Lastly, we did not explore the use of a numberother technologies that can be used to support medica-tion administration, for example, the use of bar-codes toverify medication administration and ‘smart’ infusionpumps. However in our experience, these are uncom-mon within England at present.
Future researchIn addition to the suggestions for future research aroundmedication storage, we suggest research to explore theeffects of other different medication systems and processeson MAEs and to develop potential NHS-wide interventionsto reduce MAEs. Furthermore, findings from the surveymay provide a useful starting point for future surveys tomonitor the use of hospital medication systems andprocesses. The potential future expansion of EPMA willmost probably lead to substantial changes. Thus, monitor-ing the use of different hospital medication systemswill not only facilitate prioritisation of potential NHS-wideinterventions to increase medication safety, but alsoprovide an indicator of the pace of change in the NHS.
ConclusionIn this first national survey of English hospital systems,we have described the extent of inter- and intra-hospitalvariation in medication systems. Such variations suggestthat hospital-wide EPMA is at its infancy in the majorityof hospitals, and that hospitals have implemented somecore medication systems in different ways, particularly inrelation to the use of ward-based medication storageand transport systems and the use of double-checkingpolicies for specific drugs or groups of drugs. These vari-ations may affect the generalisability of interventions toreduce MAEs, nursing staff workflow, interruptions dur-ing drug administration, and importantly, the potentialfor MAEs. Further research is needed to explore the im-plications of systems variations on MAEs directly andalso indirectly.
Additional file
Additional file 1: National survey of medication systems in EnglishNHS hospitals.
Competing interestsThe authors declare that they have no competing interests.
Authors’ contributionsAll authors contributed to conception and study design. Questionnaireformat and layout were developed by MM and ZA. Data analysis wasundertaken by MM with assistance from BDF and NB. MM was responsiblefor interpretation of the results, with assistance from BDF, NB and ZA. Thepaper was drafted by MM and all authors commented critically on thisbefore approval of the final version for submission.
AcknowledgementsThe authors would like to thank Professor Ann Jacklin for her suggestionsregarding the follow-up of some non-respondents and for her contributionto draft papers.All authors are affiliated with the Centre for Medication Safety and ServiceQuality which is affiliated with the National Institute for Health Research(NIHR) Imperial Patient Safety Translational Research Centre. The viewsexpressed are those of the authors and not necessarily those of the NHS,the NIHR or the Department of Health.ZA is funded by the School of Pharmacy Oversees Research Award(SOPORA), UCL School of Pharmacy.The funders had no role in study design; in the collection, analysis, andinterpretation of data; in the writing of the report; or in the decision tosubmit the article for publication. The researchers are independent from thefunders. All authors had full access to all of the data (including statisticalreports and tables) in the study and can take responsibility for the integrityof the data and the accuracy of the data analysis.
Author details1The Centre for Medication Safety and Service Quality, PharmacyDepartment, Imperial College Healthcare NHS Trust and Department ofPractice and Policy, UCL School of Pharmacy, London, UK. 2The HealthFoundation, 90 Longacre, London WC2E 9RA, UK.
Received: 13 September 2013 Accepted: 18 February 2014Published: 27 February 2014
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doi:10.1186/1472-6963-14-93Cite this article as: McLeod et al.: A national survey of inpatientmedication systems in English NHS hospitals. BMC Health ServicesResearch 2014 14:93.
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